Intussusception after Roux-en-Y Gastric Bypass in a Pregnant Patient

by Daniel J. Rosen, MD; Shirlee Jaffe, MD; Lawrence Cutler, MD; Alfons Pomp, MD
All from Departments of Obstetrics and Gynecology and Surgery New York Presbyterian Hospital, Weill Cornell Medical College

ABSTRACT
Intussusception is a rare complication of Roux-en-Y gastric bypass, and can present a difficult diagnostic challenge in the pregnant patient. We describe a case of a 20-year-old woman at 32 weeks gestation that presented with sudden onset abdominal pain. On exploration, an intussuception with necrotic bowel was found and resected. Intraoperatively, a cesarean section was emergently performed for active labor and breech presentation. With the increasing number of bariatric procedures being performed in obese women of childbearing age, practitioners should be aware of this serious complication.

INTRODUCTION
Roux-en-Y gastric bypass (RYGB), developed and refined over the last 40 years, is the most common weight loss procedure performed in the United States. The adoption of the laparoscopic approach improved the procedure’s morbidity and facilitated widespread acceptance and implementation.[1] RYGB achieves significant and sustained weight loss with an acceptably low complication profile. Among the most worrisome of late-presenting complications is bowel obstruction. Adhesions or internal hernias are mostly to blame, though rarely obstruction can be the result of an intussusception.[2,3] Fertility and libido increase in patients following bariatric surgery, and pregnancy in the years following surgery is not unusual.[4] Few cases pepper the literature reporting bowel obstruction in pregnant patients port-RYGB, but only one case of intussusception following RYGB complicating pregnancy has been reported.[5,6] In that case, a women, following a laparoscopic RYGB, developed an obstructive intussusception during her second trimester of pregnancy. She underwent laparoscopic reduction of the intussusception and went on to an uneventful delivery. We present the first ever reported case of a women following open RYGB treated for a third trimester intussusception that included intraoperative fetal delivery via emergency cesarean section.

CASE REPORT
The patient was a nulliparous 20-year-old woman at 32 weeks gestation who developed sudden-onset epigastric abdominal pain. She complained of nausea but denied vomiting. Pertinent history included an open retrocolic, retrogastric RYGB for morbid obesity three years earlier. She had since lost 160 pounds and had undergone subsequent incisional hernia repair. The patient appeared nontoxic, and the abdominal exam revealed a soft, gravid abdomen with mild tenderness in the epigastrium and no peritoneal signs. External fetal monitoring showed no distress, and a sonogram confirmed breech presentation with adequate amniotic fluid. Tocometer showed weak contractions at regular five-minute intervals. Vaginal exam revealed a closed cervix.

Laboratory studies were normal including a white blood cell count of 9.5 x 103. While in the emergency room, the patient’s pain intensified and she had multiple episodes of hematemesis. A computed tomography (CT) scan with intravenous (IV) and oral contrast was performed, which suggested a closed loop bowel obstruction with intestinal pneumatosis and possible volvulus (Figure 1). She was taken by the general surgery service to the operating room for diagnostic laparoscopy, with the obstetrics and pediatric services present. The patient was administered terbutaline for tocolysis and betamethasone to promote fetal lung maturation.

Upon entry into the abdomen, the Roux limb was dilated with severe venous congestion (Figure 2). The obstruction was being caused by a retrograde intussusception of the jejunojejunostomy into the distal Roux limb. The obstruction could not be reduced laparoscopically, and the procedure was converted to an open laparotomy through the previous upper midline incision. Following manual reduction of the intussusceptum, the congestion improved but the bowel viability remained questionable, so a 40-cm segment was resected.

The uterus was palpated continuously throughout the procedure and contractions were noted to increase in frequency over the course of 30 minutes, eventually occurring at every two minutes. An on-table vaginal exam showed cervical dilation to 2cm, indicating that the patient was in labor. The midline laparotomy incision was extended inferiorly and an uncomplicated emergency cesarean section was performed via a low transverse uterine incision. A male infant was delivered with an initial Apgar score of 2. The pediatric team immediately intubated him, and his Apgar score at five minutes improved to 7. The hysterotomy was then closed, and the entero-enterostomy was completed including closure of the mesenteric defect.

The patient had an uneventful postoperative course. Her infant son was discharged home on Day 19 of life after being successfully treated for bacteremia and respiratory distress. Pathology of the resected small bowel revealed ischemic enteritis with mucosal and patchy transmural necrosis.

DISCUSSION
Intussusception is a rare condition in the adult population, accounting for only 1 to 5 percent of cases of bowel obstruction.[7,8] In more than 90 percent of adult cases, a lead point can be identified, usually lymphoid hyperplasia or malignancy.[9,10] There are 17 cases of intussusceptions after RYGB reported in the literature, and, as in our patient, all occurred more than a year postoperatively and after weight loss greater than 75 pounds had occurred.[3,11,12]

The mechanism of intussusception is not clearly understood. In cases where there is a pathological lead point lesion, the trailing contiguous bowel (the intussusceptum) telescopes into adjacent proximal or distal bowel (the intussuscipiens). This traps and kinks the mesentery of the intussusceptum, causing vascular congestion, bowel wall edema, pain, and eventually ischemic necrosis. The junction between free and fixed portions of the bowel is an area particularly prone to intussusception. With normal anatomy, the ileum can intussuscept into the right colon. With surgical rerouting and anastomosis, other segments of bowel can become fixed in relation to adjacent intestine. The extreme weight loss in RYGB patients leaves a floppy mobile mesentery that gives the unfixed bowel even greater mobility to intussuscept, and staple lines in these patients may function as lead points.[13,14] RYGB can also predispose to intussusception with dysmotility of Roux limb peristalsis as documented in an actual case as well as in a dog model.[15,16]

The majority of people with intussusception present with pain, nausea, and vomiting. Peritonitis is not seen, unless necrosis or perforation has occurred. A palpable mass is rarely appreciated, even in the absence of a gravid uterus and displaced bowel.[3] In patients who have had weight loss surgery, this obstructive-type presentation should “set off alarms,” and full workup with appropriate imaging to exclude operative pathology should be undertaken. CT scan with oral and intravenous contrast is the most frequent study performed in this presentation, though the use of ultrasound or magnetic resonance imaging (MRI) would be an option, especially in the first trimester of pregnancy. Regardless of the mode of imaging, the lead point is frequently missed as it is often small and hidden within the density of the intussusceptum mass. Studies show CT sensitivity to be at 66 to 78 percent.[17]

Ultrasound is a fast study that can have high accuracy, but only in experienced hands. MRI can also capably demonstrate intussusception due to the high contrast resolution between intraluminal fluid and the bowel wall, though the study is often cumbersome to obtain, limiting its clinical usefulness in the acute setting.[18] In the second or third trimester of pregnancy, a CT scan represents little risk to the fetus and is a safe option for the rapid diagnosis of a potentially life-threatening condition to both the mother and fetus. This is especially true in the face of other equivocal study results, where definitive CT findings would influence the management decisions.[19]

In the majority of cases of intussusception, definitive diagnosis is only made at the time of operation.[7,9,10] Intraoperative reduction and/or resection of the involved bowel is mandatory to exclude irreversible ischemia and necrosis. Prognosis is variable, with mortality rates for intestinal intussusception reported between 1 and 16 percent.[10,20,21] A mortality rate of 50 percent was reported when surgical intervention was delayed by more than 48 hours after the onset of symptoms.[21] This underlines the importance of working up these patients who present with obstructive symptoms following RYGB and proceeding early to definitive diagnosis and management, ideally with diagnostic laparoscopy where appropriate.

Although intussusception in adults is rare, the incidence may be increasing with the rise of bariatric surgery. The presentation may complicate pregnancy, and at least 50 percent of patients undergoing weight loss surgery are women of childbearing age.[4] Diagnosis requires a high index of suspicion and an expeditious work up that includes appropriate imaging studies. It is essential to proceed to the operating room for exploration without undue delay even in cases where the diagnosis is equivocal. Further study is needed to better elucidate the mechanism of adult intussusception after RYGB so that the surgical techniques may be improved in an attempt to prevent or minimize the occurrence of this potentially fatal complication.

References
1.    Samuel I, Mason EE, Renquist KE, Huang YH, Zimmerman MB, Jamal M. Bariatric Surgery Trends: An 18-year report from the International Bariatric Surgery Registry. Am J Surg. 2006;192(5):657–662.
2.    Koppman JS, Li C, Gandsas A. Small bowel obstruction after laparoscopic Roux-En-Y Gastric Bypass: A review of 9,527 patients.  J Am Coll Surg. 2008;206(3):571–584.
3.    Edwards MA, Grinbaum R, Ellsmere J, Jones DB, Schneider BE. Intussusception after Roux-en-Y Gastric Bypass for morbid obesity: Case Report and Literature Review of Rare Complication. Surg Obes Relat Dis. 2006;2(4):483–489.
4.    Wax JR, Pinette MG, Cartin A, Blackstone J. Female reproductive issues following bariatric surgery. Obstet Gynecol Surv. 2007;62(9):595–604.
5.    Torres-Villalobos GM, Kellogg TA, Leslie DB, et al. Small bowel obstruction and internal hernias during pregnancy after gastric bypass surgery. Obesity Surgery. 10/2/2008 (Published Online)
6.    Wax JR, Wolff R, Cobean R, et al. Intussusception complicating pregnancy following laparoscopic roux-en-y gastric bypass. Obes Surg. 2007;17:977–979.
7.    Azar T, Berger DL. Adult intussusception. Ann Surg. 1997;226(2):134–138
8.    Zubaidi A, Al-Saif F, Silverman R. Adult intussusception: a retrospective review. Dis Colon Rectum. 2006;49(10):1546–1551.
9.    Begos DG, Sandor A, Modlin IM. The diagnosis and management of adult intussusception. Am J Surg. 1997;173(2):88–94.
10.    Barussaud M, Regenet N, Briennon X, et al. Clinical spectrum and surgical approach of adult intussusceptions: A multicentric study. Int J Colorectal Dis. 2006;21(8):834–839.
11.    Zainabadi K, Ramanathan R. Intussusception after laparoscopic roux-en-y gastric bypass. Obes Surg. 2007;17:1619–1623.
12.    Coster DD, Sundberg SM, Kermode DS, et al. Small bowel obstruction due to antegrade and retrograde intussusception after gastric bypass: three case reports in two patients, literature review, and recommendations for diagnosis and treatment. Surg Obes Relat Dis. 2008;4:69–72.
13.    Ver Steeg K. Retrograde intussusception following roux-en-y gastric bypass. Obes Surg. 2006;16:1101–1109.
14.    Duane TM, Sohlgemuth S, Ruffin K. Intussusception after roux-en-y gastric bypass. Am Surg. 2000;66:82–84
15.    Hocking MP, McCoy DM, Vogel SB, Kaude JV, Sninsky CA. Antiperistaltic and isoperistaltic intussusception associated with abnormal motility after roux-en-y gastric bypass: a case report. Surgery. 1991;110:109–112.
16.    Karlstrom L, Kelly KA. Ectopic jejunal pacemakers and gastric emptying after roux gestrectomy: effect of intestinal pacing. Surgery. 1989;106:867–871.
17.    Tan KY, Tan SM, Tan AG, et al. Adult intussusception: experience in Singapore. ANZ J Surg. 2003;73(12):1044–1047
18.    Byrne AT, Geoghegan T, Govender P, et al. The imaging of intussusception. Clin Radiol. 2005;60(1):39–46.
19.    Guidelines for Diagnostic Imaging During Pregnancy. ACOG Committee Opinion No. 299. American College of Obstetricians and Gynecologists. Obstet Gynecol. 2004;104:647–651.
20.    Ren PL, Huang JC, Shin JS, Huang CY, Fang TH. Jejunojejunogastric intussusception: a rare intussusception in an adult patient after gastric surgery. Gastrointest Endosc. 2002;56(2):296–298
21.    Archimandritis AJ, Hatzopoulos N, Hatzinikolaou R, et al. Jejunogastric intussusception presenting with hematemesis: a case report presentation and review of the literature. BMC Gastroenterol. 2001;1:1.

Tags: Intussusception, Surgical Perspective

Category: Case Report, Past Articles